The oral biology of bad breathWhy is it important?What smells?What smells too?How much does it smell?Who smells it?Where does it smell?Tongue coatingWhich bacteria are smelly?Systemic smellsOther systemic smellsIatrogenic/idiopathic smells“Psychosomatic” smellsDiagnosing smellsDiagnosis by smellingTreating smells - the basicsTongue scrapingTreating smells - short-termTreating smells - long-termTreating smells - probiotics?ADA halitosis standardsWhy so few studies?The oral biology of bad breathDENT 5301Introduction to Oral BiologyDr. Joel RudneyWhy is it important?Mouth odor can be a sign of undiagnosed diseaseMouth odor has negative connotations in many culturesAffects patient's self-imageAffects others’ attitudes towards patientBad breath is big businessMouthwashes, mints, drops, gums, toothpastesCommercials reinforce existing attitudesDentists are consulted for advice, treatmentActive marketing of "breath treatment clinic" franchisesWhat smells?Products of bacterial activityVolatile sulfur compounds (VSC)Hydrogen sulfide (H2S) - rotten eggsMethyl mercaptan (CH3SH) - natural gasMajor components of mouth odor in most personsCadaverine - diamino acid - spoiled meatAlso importantProduced independently of VSCOrganic acids - goaty smellsAcetic, propionic, butyric, isovalericWhat smells too?Products of metabolic activityVolatile food componentsGarlic, onions, etc.Broccoli, cauliflower (sulfur-rich)Ketones (acetone)Low carb dietsTrimethylamine (fishy odor)Tobacco smokeBeer, wine, and liquorHow much does it smell?Instruments for odor detectionGas chromatography of breath samplesMost informativeExtremely sensitive and preciseExpensive and cumbersomeLimited to research centersPortable sulfide meter (the Halimeter®)Can be used in a dental officeDetects only VSCMust be calibrated regularly to maintain accuracyWho smells it?Organoleptic ratings - the odor judgeTrained noses partly agree with sulfide metersMay be more relevant clinicallyRequires extensive training, periodic calibrationMainly for research, specialized clinicsThe jury of one's peersYour spouse or your best friendsYour dentist (or your patient)Relevant to the social consequences of mouth odorSelf-incrimination - least reliableMany cannot detect odors apparent to othersSome perceive odors no one else can detectWhere does it smell?Posterior tongueOdor scores associated with degree of tongue coatingTongue anatomy may increase risk (deep fissures)May be primary source of odor in younger patientsWorse with dry mouth, after sleepingPeriodontal pockets in periodontal diseaseOdor scores associated with disease/severityVSC can be measured in fluid from deep pocketsMouth odor/VSC proposed as early sign of periodontitisNot all periodontal patients have mouth odorOther oral lesions (e.g. abcesses, impactions)Oral candidiasis - "Sweet, fruity odor"Tongue coatinghttp://www.dent.ohio-state.edu/oralpath2/Tongue/25_2.jpgWhich bacteria are smelly?Tongue bacteriaStreptococcus salivarius - a sign of “health”?May be dominant in persons w/o halitosis (n = 5)Gram-negative, proteolytic anaerobesMay predispose towards halitosisMany novel species (n = 6)Digest nasal discharges, food debris, saliva components, sloughed cellsProduce VSC, cadaverineBANA hydrolysis test (Perioscan®) used for detectionPeriodontal pathogensSystemic smellsAbout 90% of halitosis originates in the mouthThe other 10%Systemic diseaseDiabetes - ketoacidosis - acetone smellCirrhosis, liver failure - "mousy", "musty" smellsRenal failure - fishy smellLeukemia - "decaying blood" smellRespiratory systemExhalation of volatile food compoundsVolatile medications - DMSO, amyl nitrateNasal/sinus/lung infectionsTonsils and tonsiloliths (may not contribute to mouth odor)•Treated by laser cryptolysisCarcinomaOther systemic smellsGastrointestinal system (considered rare)RefluxCarcinomaHelicobacter pylori infection (gastric ulcers)Genetic disorders (enzyme deficiencies)Trimethylaminuria (fishy odor) - autosomal recessiveCystinuria, cystathionuria heterozygotesRecessive defects in cysteine metabolismVery high VSC levels (gut bacteria)Iatrogenic/idiopathic smellsFrustrating to diagnose and treat - expensiveIatrogenic odorsGauze pad left behind after cleft palate surgeryForeign objectsInserted up the noseYoung children and developmentally disabledIf undetected, may lead to odor in adultsIdiopathic odorsDetectable by others, no apparent oral or non-oral causeCause presumed rare, not yet defined“Psychosomatic” smellsDetectable only by patient - no apparent causePatients often refuse to accept objective findingsAssociated with anxiety or depressionCan be confused with genetic disordersPatients may show abnormalities by gas chromatographyTrimethylaminuria heterozygotesMay be more common than once thoughtSaliva TMA detectable by patient, but not othersDiagnosing smellsHistoryOnset, duration?Constant or intermittent, morning, how long after meals?Self-report, or reported by others?Dietary factors, smoking and alcohol use?Systemic disease and medicationNeurological problems - taste and smell function?Currently under stress?Comprehensive oral examinationDiagnosis by smellingNo commercial mouth rinses for 1 day previousNo eating, drinking, brushing, gum, mints, rinses for 2 hAvoid perfumes or scented products (patient; dentist)2 min rest with lips closed - exhale through nostrils2 min rest as before - close nostrils - exhale through lips 2 min rest as before - exhale with lips and nostrils openSample posterior tongue with plastic spoonCompare odor strength for each conditionInterpretationStrongest odor with lips closed - suggests nose, sinusesStrongest odor with nostrils closed - oral or gastric sourceTongue sample to confirm oral originOdor equally strong from nose or mouth - systemicNo discernible odor - verify with others (spouse, friend)Treating smells - the basicsNon-oral etiologies - appropriate referralOral etiologiesTreat all existing conditionsAttempt to improve hygiene, flossingEncourage posterior tongue hygieneCommercial tongue scrapersMany designs on the